Increased risk of physical health problems among older autistic adults
Authors: Patricia Howlin
Journal: The Lancet Healthy Longevity (2023)

Although research involving autistic adults has been expanding steadily over the past 10 years, studies of older autistic individuals (generally defined as those aged 50 years and older) still constitute only around 0·4% of all published autism research.1Mason D Stewart GR Capp SJ Happé F Older age autism research: a rapidly growing field, but still a long way to go.Autism Adulthood. 2022; 4: 164-172Crossref PubMed Scopus (15) Google Scholar Shengxin Liu and colleagues’ study of physical health in older autistic adults2Liu S Larsson H Kuja-Halkola R Lichtenstein P Butwicka A Taylor MJ Age-related physical health of older autistic adults: a longitudinal, retrospective, population-based cohort study.Lancet Healthy Longev. 2023; (published online June 6.)https://doi.org/10.1016/S2666-7568(23)00067-3Summary Full Text Full Text PDF Scopus (1) Google Scholar is, therefore, a welcome addition to the literature. The increased risk of mental health disorders co-occurring with autism has been recognised for some time,3Lai MC Kassee C Besney R et al.Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis.Lancet Psychiatry. 2019; 6: 819-829Summary Full Text Full Text PDF PubMed Scopus (563) Google Scholar but awareness of the elevated risk of physical health problems,4Weir E Allison C Warrier V Baron-Cohen S Increased prevalence of non-communicable physical health conditions among autistic adults.Autism. 2021; 25: 681-694Crossref PubMed Scopus (26) Google Scholar higher rates of premature mortality,5Hirvikoski T Mittendorfer-Rutz E Boman M Larsson H Lichtenstein P Bölte S Premature mortality in autism spectrum disorder.Br J Psychiatry. 2016; 208: 232-238Crossref PubMed Scopus (474) Google Scholar and of the many barriers that autistic people face in accessing adequate health care is now growing as well.6Mason D Ingham B Urbanowicz A et al.A systematic review of what barriers and facilitators prevent and enable physical healthcare services access for autistic adults.J Autism Dev Disord. 2019; 49: 3387-3400Crossref PubMed Scopus (99) Google Scholar The study by Liu and colleagues has several important strengths, one of which is the large sample size. The authors used data from Sweden's Total Population Register and National Patient Register to compare the health records of over four million non-autistic adults with those of 5291 autistic adults (1930 [36·5%] women and 3361 [63·5%] men; 1105 (20·9%) with a co-occurring intellectual disability). A wide breadth of health conditions, selected on the basis of a recent systematic analysis for the Global Burden of Disease Study 2019,7Vos T Lim SS Abbafati C et al.Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet. 2020; 396: 1204-1222Summary Full Text Full Text PDF PubMed Scopus (4974) Google Scholar was investigated. The maximum age of participants (up to 81 years) is higher than in many other studies of older autistic adults, and the wide range of health conditions studied allowed the identification of conditions that this older cohort is at higher risk of—namely, bodily injuries, gastrointestinal tract diseases, anaemia, osteoarthritis, endocrine and metabolic disorders, pulmonary and cardiovascular conditions, and self-harm. In line with some previous research,8Bishop-Fitzpatrick L Rubenstein E The physical and mental health of middle aged and older adults on the autism spectrum and the impact of intellectual disability.Res Autism Spectr Disord. 2019; 63: 34-41Crossref PubMed Scopus (56) Google Scholar the presence of intellectual disability was not associated with higher rates of ill health, although differences were noted in the types of conditions identified in subsets of the study population (eg, higher rates of bodily injury and falls in autistic individuals with intellectual disability than in those without intellectual disability, and higher rates of intentional self-harm in those without intellectual disability than in those with intellectual disability). No differences in overall rates of health conditions by sex were noted, although the risk for specific conditions differed between men and women. The information provided by Sweden's extensive population and health registers has been shown to be invaluable for the identification of health risks in this large population of autistic adults. Moreover, because the health care system in Sweden is largely tax-funded, the data are not subject to the potential biases inherent to insurance-based health registers, such as those that are commonly used in studies in the USA. Nevertheless, the limitations should be noted. Firstly, the patient register did not include primary care or outpatient contacts before 2001, and thus some diagnoses might have been missed. Although the authors suggest that this aspect is unlikely to have affected the identification of autism, only 0·13% of the total cohort had an autism diagnosis recorded, which differs greatly from current autism prevalence estimates (almost ten times that figure9Zeidan J Fombonne E Scorah J et al.Global prevalence of autism: a systematic review update.Autism Res. 2022; 15: 778-790Crossref PubMed Scopus (305) Google Scholar). Although autistic individuals are known to often face substantial challenges in accessing health care,6Mason D Ingham B Urbanowicz A et al.A systematic review of what barriers and facilitators prevent and enable physical healthcare services access for autistic adults.J Autism Dev Disord. 2019; 49: 3387-3400Crossref PubMed Scopus (99) Google Scholar access barriers alone are unlikely to explain the very low proportion of autistic participants in this study. Secondly, although register-based records provide a wealth of quantitative information, by their very nature, they are rarely suitable to explore crucial qualitative issues. The authors highlight the scarcity of knowledge on the potential effect of genetic factors, but many other factors influencing susceptibility to ill health are yet to be explored. Thus, the data do not provide information on the extent of participants’ autistic characteristics, the severity of their physical conditions, their mental health, or the associations between these factors. In addition, although the analyses take account of sex at birth, the influence of gender is unexplored, and the effects of social, economic, cultural, and other factors also remain unknown. In conclusion, this large comparative study highlights the increased risk of physical ill health and injuries in older autistic adults. The authors rightly stress the “urgent need to understand the underlying reasons, design targeted screening and intervention programmes, and promote older care to enhance quality of life for older autistic people”. However, a record-based study such as this can only be the first step towards meeting these goals. Much more detailed research, both quantitative and qualitative, is needed to explore the influence of autistic traits, individual characteristics, and social circumstances on the developmental trajectories of physical health disorders in autism. Only then will it be possible to begin exploring possible preventative strategies and develop effective care interventions. I declare no competing interests. Age-related physical health of older autistic adults in Sweden: a longitudinal, retrospective, population-based cohort studyOur data indicate that older autistic adults are at substantially increased risk of age-related physical conditions and injuries compared with non-autistic adults. These findings highlight the need for collaborative efforts from researchers, health services, and policy makers to provide older autistic individuals with the necessary support to attain healthy longevity and a high quality of life. Full-Text PDF Open AccessA primary care model to improve quality of life for older autistic peopleThe Article by Liu and colleagues1 and the accompanying Comment by Howlin,2 reporting on older autistic adults’ substantially increased risk of age-related physical conditions compared with non-autistic adults, stresses the “urgent need to understand the underlying reasons, design targeted screening and intervention programmes, and promote older care to enhance quality of life for older autistic people”. Although the study was in the Swedish population, the English example of targeted screening and intervention programmes for this patient group could provide be of practical utility. Full-Text PDF Open Access